FNS-844 Report of Disqualification from Participation-Individual

OMB APPROVED NO. 0584-0000
Expiration Date: XX/XX/XXXX

Department of Agriculture, Food and Nutrition Service

REPORT OF DISQUALIFICATION FROM PARTICIPATION INDIVIDUALLY DISQUALIFIED RESPONSIBLE PRINCIPAL/INDIVIDUAL
OR DAY CARE HOME PROVIDER
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it contains
a valid OMB control number. The valid OMB number for this collection is 0584-XXXX. The time required to complete this information
collection is 30 minutes per response, including the time to review instructions, to search existing data resources, to gather the data
needed, and to complete and review the information collection.
Section 243(c) of Public Law 106-224, the Agricultural Risk Protection Act of 2000, amended § 17(d)(5) of the Richard B. Russell
National School Lunch Act (42 U.S.C. 1766 (d)(5)(E)(i) and (ii)) by requiring the Department of Agriculture to maintain a list of
institutions, day care home providers, and individuals that have been terminated or otherwise disqualified from Child and Adult Care
Food Program (CACFP) participation. The law also required the Department to make the list available to State agencies for their use in
reviewing applications to participate and to sponsoring organizations to ensure that they do not employ as principals any persons who
are disqualified from the Program. This statutory mandate has been incorporated into § 226.6(c)(7) of the CACFP regulations.
Instructions: Within the National Disqualified List web-based system, users click on “Add Individual” on the task bar to add the
disqualification information of an individual (i.e., Day Care Home Provider or an Independent Responsible Principal/Individual. When
adding an individual, fields that are marked with an “*” are required to be completed in order to save the record.
Upon entering the address, users click on “Validate Address”. If the system does not recognize the address, an error message is
displayed and the user must alter the address or override the validation.
Select at least one disqualification reason. If “Other” is selected, it must be explained in the “Additional Comments” section.
If the entered data passes all validations, the individual information is saved into the system when the “Save” button is clicked. After
saving the information, State agency users cannot edit the information. If any changes need to be made to the saved record, State
agency users must contact the FNS Regional Office to modify the record. After successfully saving the record, the status of the newly
added individual record is set to “Pending Review”. It will display this status until the FNS Regional Office approves the record for
inclusion on the NDL.

FORM FNS-844 (05-13) Previous Editions Obsolete

SBU

Electronic Form Version Designed in Adobe 10.0 Version

Individual
Personal Information
First Name:

Middle Name:

Date of Birth:

Street Number:

Last Name:

Street Name/PO Box Number:

Additional Address Information:
City:

State/Province:

Zip Code:
Note: Users have the ability to validate the address within the
National Disqualified List web-based system.

Other Names: (Please enter other names below.)
First Name:

Middle Name:

Last Name:

Disqualification Information
State Agency Imposing Disqualification:

Region:

Termination Date:

Type of Individual Disqualification:

Debt Owed:
Yes

Original Debt Amount: (Please enter the amount in U.S. dollars)
No

Amount Paid: (Please enter the amount with interest in U.S. dollars)

Date Debt Paid in Full:

Name of Provider's Sponsoring Organization or Responsible
Principal/Individual's Institutional Affiliation:

Individual's Title with Organization:

Disqualification Reasons: (Please select one or more disqualification reasons as applicable)
Submission of false claims for reimbursement.
Simultaneous participation under more than one sponsoring organization.
Failure to keep required records.
A determination that the day care home has been convicted of any activity that occurred during the past seven years and that indicated a lack of business integrity. A
lack of business integrity includes fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements,
receiving stolen property, making false claims, obstruction of justice, or any other activity indicating a lack of business integrity as defined by the State agency, or the
concealment of such a conviction.
Failure to participate in training.
Submission of false information on application.
Other
Non-compliance with the Program meal pattern.
Conduct or conditions that threaten the health or safety of a child(ren) in care, or the public health or safety.
Any other circumstance related to non-performance under the sponsoring organization-day care home agreement, as specified by the sponsoring organization or the
State agency.

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